Benevolence Fund Medical Assistance
Contact Information
Full Name
(Required)
Email
(Required)
Phone
(Required)
Alternate Phone
Address
Address Line 1
(Required)
Address Line 2
City
(Required)
State
(Required)
Zip
(Required)
Employment Information
Community / Location
(Required)
Work City
(Required)
Work State
(Required)
Job Title
(Required)
Date of Hire
(Required)
Work Schedule
Employment Status (Full Time / Part Time)
Weekly Hours
Applicant Type
Are you the applicant?
(Required)
Yes
No
Applicant Name
(Required)
Relationship
(Required)
Hardship Basics
Date(s) of hardship
(Required)
Description of situation
(Required)
Financial Request
Amount Requested
(Required)
How funds will be used
(Required)
Medical Details
Description of condition
Household Impact
Medical bills?
Yes
No
Total
(Required)
Other assistance applied for?
Yes
No
Payment plan attempted?
Yes
No
Coverage
Insurance?
Yes
No
Other coverage?
Yes
No
Work Impact
FMLA/Leave?
Yes
No
PTO exhausted?
Yes
No
Lost wages?
Yes
No
Cause
Work-related injury?
Yes
No
Workers comp filed?
Yes
No
Disability benefits?
Yes
No
Auto accident?
Yes
No
*Required fields
